Healthcare Provider Details

I. General information

NPI: 1619540077
Provider Name (Legal Business Name): LIFE FULFILLMENT AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4335 W PIEDRAS DR STE 103
SAN ANTONIO TX
78228-1215
US

IV. Provider business mailing address

21916 PARK VIEW DR
GARDEN RIDGE TX
78266-2749
US

V. Phone/Fax

Practice location:
  • Phone: 210-600-4117
  • Fax: 210-600-3849
Mailing address:
  • Phone: 210-844-9985
  • Fax: 210-600-3849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. IMELDA RAMIREZ REVERON
Title or Position: CEO/ADMINISTRATOR
Credential: MHC
Phone: 210-600-4117